Hartmann's procedure versus primary anastomosis for Hinchey stage III diverticulitis: a prospective case-control study.

INTRODUCTION: Hartmann's procedure (HP) is the conventional treatment in patients with complicated diverticulitis. Segmental resection with primary anastomosis (PA) is a treatment alternative for those patients. Our aim was to compare the postoperative results of HP and PA in patients with complicated diverticulitis (Hinchey stage III). METHODS: A case-control study was conducted on patients operated on for purulent Hinchey stage III diverticulitis, within the time frame of 2000 and 2019. RESULTS: Twenty-seven patients that underwent PA were compared with 27 that underwent HP. The patients that underwent HP had a greater probability of morbidity at 30 days (OR 3.5; 95% CI 1.13-11.25), as well as a greater probability of major complications (OR 10.9; 95% CI 1.26-95.05). CONCLUSION: The patients that underwent segmental resection and PA presented with lower morbidity rates and higher stoma reversal rates than the patients that underwent HP.

Damage control in penetrating duodenal trauma: less is better - the sequel.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Damage control in penetrating duodenal trauma: less is better - the sequel / El control de daños en trauma penetrante de duodeno: "Menos es Mejor

Abstract The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

Resumen El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? / Cirugía de control de daños en lesiones combinadas de intestino delgado y colon en trauma penetrante: ¿Es pertinente el uso de ostomías?

Abstract Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Safety and feasibility of laparoscopic sigmoid resection without diversion in perforated diverticulitis.

BACKGROUND: Laparoscopic primary anastomosis (PA) without diversion for diverticulitis has historically been confined to the elective setting. Hartmann's procedure is associated with high morbidity rates that might be reduced with less invasive and one-step approaches. The aim of this study was to analyze the results of laparoscopic PA without diversion in Hinchey III perforated diverticulitis. METHODS: We performed a retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic sigmoidectomy for diverticular disease during the period 2000-2018. The sample was divided in two groups: elective laparoscopic sigmoid resection for recurrent diverticulitis (G1) and emergent laparoscopic sigmoidectomy for Hinchey III diverticulitis (G2). Demographics, operative variables, and postoperative outcomes were compared between groups. RESULTS: A total of 415 patients underwent laparoscopic sigmoid resection for diverticular disease. PA without diversion was performed in 351 patients; 278 (79.2%) belonged to G1 (recurrent diverticulitis) and 73 (20.8%) to G2 (perforated diverticulitis). Median age, gender, and BMI score were similar in both groups. Patients with ASA III score were more frequent in G2 (p: 0.02). Conversion rate (G1: 4% vs. G2: 18%, p < 0.001), operative time (G1: 157 min vs. G2: 183 min, p < 0.001), and median length of hospital stay (G1: 3 days vs. G2: 5 days, p < 0.001) were significantly higher in G2. Overall postoperative morbidity (G1: 22.3% vs. G2: 28.7%, p = 0.27) and anastomotic leak rate (G1: 5.7% vs. G2: 5.4%, p = 0.92) were similar between groups. There was no mortality in G1 and one patient (1.3%) died in G2 (p = 0.21). CONCLUSION: Laparoscopic sigmoid resection without diversion is feasible and safe in patients with perforated diverticulitis. In centers with vast experience in laparoscopic colorectal surgery, patients undergoing this procedure have similar morbidity and mortality to those undergoing elective sigmoidectomy.

Sigmoidectomy with primary anastomosis for complicated diverticulitis.

BACKGROUND: It is possible to resect the perforated segment and reestablish intestinal continuity with adequate morbidity and mortality results in patients with complicated diverticulitis. AIMS: To evaluate the type of surgery performed at our center and the results of the procedures in patients with complicated diverticulitis. MATERIAL AND METHODS: All patients that underwent sigmoidectomy due to complicated diverticulitis within the time frame of 2005-2012 were included in the study. The primary objective was to evaluate the type of surgery performed. The secondary objective was to evaluate patient morbidity and mortality after 30 postoperative days. RESULTS: The study included 77 patients with a mean age of 51.17±12.80 years. The majority of the patients were men (64.9%) (n=50) and the mean BMI was 28.24±4.06kg/m2. A total of 63.6% (n=49) patients presented with a Hinchey iii-iv classification. Sigmoidectomy with primary anastomosis was performed in 58.4% (n=45) of the patients, 48.8% (22/45) of whom presented with Hinchey iii-iv. Primary anastomosis was more frequently performed in patients that had Hinchey i-ii(P=.001). Open surgery was carried out in 85.7% (n=66) of the cases. The mean surgery duration was longer in the patients with primary anastomosis (181.73±68.2min vs. 152.13±65.8min) (P>.05). Colorectal surgeons performed the procedures in 44.2% (n=34) of the cases. Complications presented in 23.4% (n=18) of the patients and there was a tendency toward more complications in patients that underwent the Hartmann's procedure. The mortality rate was 2.6% (n=2). CONCLUSIONS: Sigmoidectomy with primary anastomosis is a frequent surgery in patients with complicated diverticulitis at our hospital. There was no difference in morbidity and mortality, compared with the Hartmann's procedure.

Procedimiento de Hartmann vs resección y anastomosis primaria en peritonitis diverticular de colon izquierdo por cirugía abierta: revisión sistemática de la literatura / Hartmann’s procedure and resection with primary anastomosis in diverticular peritonitis

Introduction: colonic diverticulosis, as diverticulitis, is a frequent disease in different stages of evolution. There is uncertainty about treatment options that are used in secondary peritonitis. The aim of this study is to determine the best treatment option for patients with peritonitis secondary to diverticulitis of the left colon in terms of postoperative morbidity (POM) and mortality, comparing Hartmann's procedure (HP) and resection with primary anastomosis (RPA). Material and Methods: systematic review. Studies in adults with peritonitis secondary to diverticulitis of the left colon treated with HP and RPA published between 1990 and 2011 were analyzed. TRIPDATABSE, IWO, MEDLINE, SciELO and LILACS databases were consulted and search strategies were applied using MeSH and free terms. Selected studies were analyzed using a score of methodological quality (MQ). The following variables were considered: mortality, POM, hospital stay, percentage of bowel transit reconstitution in patients undergoing HP and MQ of primary studies. Results: 26 primary studies were analyzed (47 series). There were no significant differences in the variable mortality (p = 0.0805), but significant difference was observed in POM (incompletely reported) (p = 0.0187). The median of MQ of the studies was 11 points for HP series and 10 for RPA series. Conclusion: the available evidence to determine the best treatment option in terms of mortality and POM in this kind of patients is insufficient. Studies with better level evidence and MQ are needed to clarify the uncertain.

Introducción: la enfermedad diverticular del colon es una entidad frecuente, como también la diverticulitis en sus diferentes estadios de evolución. Existe incertidumbre respecto de las opciones terapéuticas que se utilizan en el tratamiento de la peritonitis diverticular de colon izquierdo (PDCI). El objetivo de este estudio es determinar la mejor opción de tratamiento para pacientes con PDCI entre procedimiento de Hart-mann (PH) y resección con anastomosis primaria (RAP), en términos de mortalidad y morbilidad postoperatoria (MPO). Material y Método: revisión sistemática de la literatura. Se analizaron estudios realizados en adultos con PDCI tratados con PH y RAP, publicados entre 1990 y 2011. Se consultó en las bases de datos TRIPDATABSE, IWO, MEDLINE, SciELO y LILACS, utilizando estrategias de búsqueda con términos MeSH, palabras libres y operadores booleanos. Los estudios seleccionados fueron analizados mediante un escore de calidad metodológica (CM). Se consideraron las variables mortalidad, MPO, estadía hospitalaria, porcentaje de reconstitución de tránsito en pacientes sometidos a PH y CM de los estudios primarios. Resultados: se analizaron 26 estudios primarios (47 series de pacientes). No se encontraron diferencias significativas respecto de la variable mortalidad (p = 0,0805); pero sí en la variable MPO, reportada de forma incompleta (p = 0,0187). La mediana de la CM de los estudios primarios fue de 11 puntos para las series de PH y de 10 para las de RAP. Conclusión: la evidencia disponible no permite determinar la mejor alternativa terapéutica en términos de mortalidad y MPO en este tipo de pacientes. Se requieren estudios de mejor nivel de evidencia y CM para aclarar esta incertidumbre.

Anastomosis primaria en enterocolitis necrotizante / Primary anastomosis in necrotizing enterocolitis

Introduction: Necrotizing Enterocolitis (NE) is the most frequent gastrointestinal emergency among newborns (NB). Thirty percent of them require surgical treatment, with resection of the damaged intestinal segment and stoma formation. In some cases, primary resection and anastomosis can be considered. Objective: To review the use of primary anastomosis on NE in 2 pediatric centers, one public hospital and one private clinic. Patients and Method: A retrospective, descriptive study of all NB with NE managed with primary anastomosis at Hospital Exequiel González Cortés y Clínica Las Condes between December 2004 and december 2009. The population was divided into Group A: Unifocal, and Group B: Multifocal intestinal involvement. The following variables were evaluated and compared: gestational age, weight, use of peritoneal drains, characteristics of the resected segment, number of anastomoses, requirement of parenteral nutrition, postoperatory complications. Results: Sixty NB were surgically repaired with primary anastomosis. 12 percent presented birth weight <1.000grams, 22 percent between 1000-1500 grams. In 18 patients 2 anastomoses were performed in different intestinal segments. Postoperatory complications included wound infection in 3 cases and dehiscence of the anastomosis in 1 case. 7 percent evolved with short loop syndrome. Mortality was 11,6 percent, secondary to sepsis. Conclusions: In this experience, Primary Anastomosis in NE appears to be a safe option, with low morbimortality despite the age, weight, IP contamination or extension of the disease.

Introducción: Enterocolitis Necrotizante (ECN) es la emergencia gastrointestinal más común del recién nacido (RN), 30 por ciento requiere tratamiento quirúrgico, con resección del segmento intestinal dañado, realizando luego una ostomía en la mayoría. En recientes casos la resección intestinal y anastomosis primaria han sido reportados en forma exitosa. Objetivo: Evaluar la experiencia del manejo con anastomosis primaria en ECN en 2 centros pediátricos, un Hospital público y una Clínica privada. Pacientes y Método: Estudio descriptivo retrospectivo. Se incluyó a RN del Hospital Exequiel González Cortés y Clínica Las Condes con ECN manejados con anastomosis primaria, entre diciembre de 2004 y diciembre de 2009. Se dividieron en Grupo A: Unifocal; Grupo B: Compromiso intestinal multifocal. Se comparó entre ambos grupos: edad gestacional, peso, utilización de drenajes peritoneales, características del segmento resecado, número de anastomosis, requerimientos de nutrición parenteral, complicaciones postoperatorias. Resultados: Se sometió a cirugía con anastomosis primaria a 60 recién nacidos. El peso de nacimiento fue < 1 000 g en el 12 por ciento, 1 000-1 500 g el 22 por ciento, y el resto >1 500 g. En 18 pacientes del grupo B se realizaron 2 anastomosis en segmentos intestinales diferentes. Las complicaciones postoperatorias fueron infección de herida operatoria (n:3) y dehiscencia de anastomosis (n:1). Un 7 por ciento evolucionó con síndrome de intestino corto. La mortalidad fue 11,6 por ciento, en todos los casos secundaria a sepsis. Conclusiones: En esta experiencia la Anastomosis Primaria en ECN aparece como una opción segura, con baja morbimortalidad independiente de la edad, peso, contaminación intraperitoneal o extensión de la enfermedad.